(SBQ12TR.100) The treating surgeon, concerned that his hospital does not have a plastic surgeon available for soft-tissue coverage, arranges for transfer of the patient to a nearby level I trauma center for definitive care. He sustained an injury to his right leg as seen in Figures A and B. They can also be classified by the mechanism or direction of force applied to the injured ankle. bypass fracture, likely adjacent joint (i.e. (SBQ04PE.60) (OBQ04.114) Contralateral lower extremity open fracture(s). (OBQ09.128) It is a safe procedure if the correct timing is respected, usually 5-10 days after initial trauma. Distal Humerus Fractures are traumatic injuries to the elbow that comprise of supracondylar fractures, single column fractures, column fractures or coronal shear fractures. Which of the regions on the patient's injury AP radiograph in Figure A, if not addressed properly during surgery, represents a risk for radiocarpal instability? Copyright 2022 Lineage Medical, Inc. All rights reserved. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Early intravenous antibiotic administration, Irrigation and debridement of the open fracture with 9L of solution, Vacuum assisted dressings over skin deficit. On physical exam she has no sensation of the volar thumb, index, and middle fingers. open reduction internal fixation of the fibula only, open reduction internal fixation of the tibia and fibula, removal of external fixator and conversion to a walking cast. CT scan is helpful for intra-articular assessment and operative planning. (OBQ04.216) A 45-year-old male presents with the fracture seen in Figures A and B after a motor vehicle collision. A 32-year-old man sustains the knee injury seen in Figure A after falling from a ladder. Which of the following statements comparing the techniques in Figure B and C is most accurate? Inability to extend the index finger proximal interphalangeal joint. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. A 32-year-old male sustains the closed injury shown in Figure A. Temporary external fixation then lateral percutaneous screws, Lateral nonlocking plate +/- bone graft substitutes, Medial and lateral locking plate +/- bone graft substitutes, Lateral percutaneous screws with assisted arthroscopy. A 21-year-old male sustains the open injury shown in Figure A, which is associated with a 12 centimeter laceration over the fracture site. (OBQ07.60) The injury is closed, and soft tissues are intact upon arrival. When the closure of only a part of the plate occurs, angular deformities may be present. difficulty or . After removing the external fixator and plating the fibula, what would be next step in the operative plan for reduction and fixation of this injury? Which of the following options is the most biomechanically stable and appropriate definitive surgical treatment? (OBQ09.228) Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. The limb remains neurovascularly intact. A 45-year-old male laborer falls off a 15 foot retaining wall 6 hours ago and sustains an open fracture shown in Figures A through C. He has a normal neurovascular exam. Continued use of knee-spanning external fixator, Conversion of external fixator to a simple hinged knee fixator, Open reduction and internal fixation with a lateral locked plate, Open reduction and internal fixation with medial and lateral plates. (OBQ16.228) What adjunct treatment has been shown to improve outcomes when using an intramedullary nail? Distal femur fracture. A 69-year-old female sustains the injuries seen in Figures A and B. paralyzed), or those unfit for surgery, angulation and rotational alignment are well maintained with casting, however, shortening is hard to control, risk of shortening higher with oblique and comminuted fracture patterns, risk of varus malunion with midshaft tibia fractures and an intact fibula, high success rate if acceptable alignment maintained, non-union occurs in approximately 1% of patients treated with closed reduction, all open tibia fractures require an emergent I&D, surgical debridement within 12-24 hours of injury, wounds should be irrigated and dressed with saline-soaked gauze in the emergency department before splinting, all open tibia fractures require immediate antibiotics, should be administered within 3 hours of injury, standard abx for open fractures (institution dependent), cephalosporin given continuously for 24 hours, after definitive surgery in Grade I, II, and IIIA open fractures, aminoglycoside added in Grade IIIB injuries, tetanus vaccination status should be confirmed and appropriate prophylaxis should be administered if necessary, early antibiotic administration is the most important factor in reducing infection, emergent and thorough surgical debridement is also an, must remove all devitalized tissue including cortical bone, open fractures with soft tissue defects/contamination, uniplanar, circular, hybrid external fixators all available, should be converted to intramedullary nail within 7-21 days, ideally less than 7 days, longer time to union and worse functional outcomes, high rate of pin tract infections; avoid intra-articular placement given risk for septic arthritis, unacceptable alignment with closed reduction and casting, soft tissue injury that will not tolerate casting, ipsilateral limb injury (i.e., floating knee), reamed nailing allows for larger diameter nail, provisional reduction techniques (blocking screws, plating, etc), particularly useful for proximal 1/3 tibial shaft fractures, for closed tibia fractures treated with nailing, risks for nonunion: gapping at fracture site, open fracture and transverse fracture pattern, shorter immobilization time, earlier time to weight-bearing, and decreased time to union compared to casting, decreased malalignment compared to external fixation, improved fracture alignment with suprapatellar nailing, reamed may have higher union rates and lower time to union than unreamed nails in closed fractures (controversial), reamed nails are safe for use with open fractures, with no evidence of decreased nonunion rates in open fractures, recent studies show no adverse effects of reaming (infection, embolism, nonunion), reaming with the use of a tourniquet is not associated with thermal necrosis of the tibial shaft, despite prior studies suggesting otherwise, higher rate of locking screw breakage with unreamed nailing, proximal tibia fractures with inadequate proximal fixation from IM nailing, distal tibia fractures with inadequate distal fixation from IM nail, tibia fractures in the setting of adjacent implant/hardware (i.e. Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist, Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands, accounts for 17.5% of all fractures in adults, younger patients due to high energy mechanisms, older patients due to low energy mechanisms (i.e. (OBQ06.102) She undergoes simultaneous external fixation and ORIF using minimally invasive plate osteosynthesis. Fractures of the Distal Tibial Metaphysis with Intra-articular ExtensionThe Distal Tibial Explosion Fracture Article Sep 1979 J TRAUMA James F Kellam J.P. Waddell View Show abstract. Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient? Thank you. 1. A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. more common in diaphyseal tibial shaft fractures than proximal or distal tibia fractures 8.1% risk in diaphyseal fractures, compared to proximal (1.6%) and distal (1.4%) fractures can occur even in the setting of an open fracture Radiographs and CT are shown in Figures A through C. What is the most appropriate surgical plan based on the images provided? A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. (OBQ07.182) Increased pulmonary morbidity post-operatively, Increased cortical bone temperature during reaming. They are also called tibial plafond fractures. Coronal and sagittal CT scan images are shown in Figures D and E. What is the MOST appropriate next step in management in addition to operative irrigation and debridement? Gentle compressive loading of the affected joint through early range of motion exercises, Strict joint immobilzation for three weeks, Joint distraction with a spanning external fixator for three weeks, Glucosamine chondroitin sulfate supplementation. Infected tibial shaft nonunion 6 months status post intramedullary nail fixation, Oligotrophic humeral shaft nonunion 7 months status post non-operative management, Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation, Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation, Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws. During operative fixation, free osteoarticular fragments are encountered and reconstruction of these pieces is attempted. (OBQ06.60) Due to the asymmetrical closure of the distal tibial physis (Figure 1) during early adolescence, transitional fractures can also occur. Distal femoral nonunion with less than 10% bone loss, Mid-diaphyseal humeral nonunion with less than 10% bone width loss, Proximal humeral shaft nonunion with less than 10% bone width loss, Diaphyseal tibial shaft nonunion with less than 30% cortical width bone loss. He is initially taken to a local hospital. What is the most appropriate treatment? What is the most appropriate initial management of the patient's injuries in . (OBQ08.51) 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Fracture Non-Spanning External Fixator, Distal Radius Fracture Spanning External Fixator, Type in at least one full word to see suggestions list, 7th Annual Frontiers in Upper Extremity Surgery, Nonoperative Treatment of Distal Radius Fractures - Michael Bednar, MD, Dorsal Plating of Radius Fractures - Nader Paksima, DO, MPH, Fragment Specific Fixation Distal Radius Fractures - Mark Rekant, MD, 12th Annual Orthopaedic Trauma: Pushing The Envelope. A 30-year-old patient sustains a comminuted tibia fracture and is treated with minimally invasive plating, shown in Figure A. Tibial plateau fractures are periarticular injuries of the proximal tibia frequently associated with soft tissue injury. (OBQ04.34) Laboratory workup for infection is negative. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. AO Davos Courses 2022. Examination reveals full motion of the right hip, knee, and ankle. A retrospective study of two hundred and thirty-seven cases in children. A tourniquet is used for the tibial nailing portion of the case, and the tibial isthmus is over reamed to accept a larger nail. (OBQ13.211) Based on the following radiographs of tibial plateau fractures, which one is most likely to have a concomitant medial meniscus tear? A 28-year-old man is thrown from his motorcycle and sustains the closed injury seen in Figure A. Which of the following is most important to long-term success in surgical treatment of this case? (OBQ07.76) What is the likely mechanism of her paresthesias and what is the most appropriate treatment? CT scan is helpful for intra-articular assessment and operative planning. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. Treatment is immobilization or surgery, depending on the displacement and stability of the distal clavicle, as determined by whether coracoclavicular (CC) ligaments (trapezoid and conoid) are intact. A 25-year-old male pedestrian sustained a Type II open tibia fracture after being struck by a car at 10:00PM. Evaluation of volar compartment pressures with a needle monitor, Icing and elevation of the arm with follow-up evaluation in 8 hours, Immediate EMG evaluation of the left upper extremity, Closed reduction, carpal tunnel release, and sugar tong splinting, Emergent open reduction internal fixation with carpal tunnel release. She also complains of some paresthesias in her thumb and index finger. . Knee dislocation. Gustilo 3A with spanning external fixation and delayed definitive fixation with soft tissue coverage, Gustilo 3A with immediate medial and lateral plating followed by delayed soft tissue coverage, Gustilo 3B with spanning external fixation and delayed definitive fixation with soft tissue coverage, Gustilo 3B with immediate medial and lateral plating followed by delayed soft tissue coverage, Gustilo 3C with spanning external fixation and delayed definitive fixation with soft tissue coverage. Symptoms of tibia fracture. Radiographs of the tibia and fibula are provide in Figures A and B. His wounds healed without infection or other complications. This paper was presented at the OTA 2021 Annual Meeting. A 27-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A through E. The articular surface is depressed 2 mm while there is 3 mm of condylar widening. Coronoid Fx - Open Reduction Internal Fixation with Screws. Radiographic features Which of the following distal radius fractures is associated with volar translation of carpus relative to the radial articulation? Patella fracture. A 65-year-old female sustains a fall onto her outstretched right hand. Two-point discrimination is now >10mm in these fingers. A 35-year-old male has a closed mid-shaft tibia fracture following a skiing accident. For prognostic reasons, severely comminuted, contaminated barnyard injuries, close-range shotgun/high-velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been included in the grade III group. What is the most likely etiology of her new loss of function? (OBQ06.193) You review his operative note in which the surgeon reports having to apply a volar locking plate in a distal position to secure the difficult intra-articular fracture. A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. The femoral and tibial plateau fractures are open with no gross contamination, and there is an ipsilateral Morel-Lavelle lesion of the left thigh. Which of the following is the most significant risk factor for lateral meniscal tears associated with lateral tibial plateau fractures? (SBQ17SE.70) Extensor carpi radialis longus transfer to extensor pollicus longus, Extensor pollicis brevis transfer to extensor pollicus longus, Extensor indicis proprius transfer to extensor pollicus longus, Primary repair of extensor pollicus longus. A 45-year-old patient sustains the injury shown in figure A. (OBQ08.14) (OBQ18.223) (OBQ09.254) You can rate this topic again in 12 months. Carpal tunnel release if no resolution at 6-12 weeks. if skin cannot be closed, vac-assisted closure should be considered in short-term. Tibial plateau fractures are periarticular injuries of the proximal tibia frequently associated with soft tissue injury. When placing an intramedullary nail for closed distal tibia shaft fractures, all of the following methods are described techniques to aid anatomic reduction EXCEPT: Percutaneous placement of reduction foreceps at the fracture site, Placing a small-fragment plate at the fracture site. No erythema is appreciated. The diagnosis and management of fibular fractures is discussed here. Which of the following is true regarding the center of rotation of angulation (CORA) as it refers to tibial diaphyseal angular deformity? A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. (OBQ10.176) She sustained the isolated, closed injury shown in Figures A and B. Download as PDF. Association with posteromedial corner of the knee injury, Association with anterior tibial artery injury, Possible need for single extensile anterior approach to the knee. What is the most likely diagnosis?l, Nondisplaced oblique or spiral fracture of the tibia with an intact fibula, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, PediatricsTibial Shaft Fractures - Pediatric, Open Tibial Shaft Fracture in an 11 Years Male, Pediatric Open Distal Tibial Shaft Fracture. Which of the following fracture patterns is classically associated with varus malunion if treated with closed reduction and casting? Epiphyseal fractures of the distal ends of the tibia and fibula. A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. Which of the following interventions should be taken? Serum vitamin D, calcium, and phosphate levels. He sustains the injury shown in Figure A. (OBQ12.199) A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I: A post-fixator CT scan image is shown in Figure C. After allowing her soft tissues to improve, the optimal definitive stabilization of this fracture is which of the following? Initial management is often provided by primary care and emergency clinicians, who must therefore be familiar with these injuries. Passive knee range of motion is limited to 15 degrees. Isolated exchange reamed interlocking nailing is most likely indicated as the next step in treatment for which of the following clinical scenarios: Tibial shaft nonunion with a 4cm bone defect, Hypertrophic metadiaphyseal distal tibia nonunion. Treatment is generally operative with temporary external fixation followed by delayed open reduction internal fixation once the soft tissues permit. This a case of a traumatic progressively displaced DTMF despite cast . (OBQ04.233) After debridement and external fixation, he is taken to the operating room for definitive soft tissue flap coverage and intramedullary nailing. (OBQ09.187) You decide to treat this fracture with intramedullary nailing. Plain radiographs are negative. (SBQ17SE.13) Which of the following injuries is most likely associated with the fracture seen in Figure A? Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Diagnosis is typically made through clinical evaluation and confirmed with plain radiographs. ORIF with medial and lateral plating with grafting of metaphyseal defect, ORIF with lateral plating with grafting of metaphyseal defect, Percutaneous articular fragment reduction and screw fixation. check firmness of each compartment to evaluate for compartment syndrome, dorsalis pedis and posterior tibial pulses - compare to contralateral side, CT angiography indicated if pulses not dopplerable, full-length AP and lateral views of the affected tibia, AP, lateral and oblique views of ipsilateral knee and ankle, repeat radiographs recommended after splinting or fracture manipulation, intra-articular fracture extension or suspicion of plateau/plafond involvement, used to exclude posterior malleolar fracture, high variation in reported incidence of posterior malleolus fracture with distal 1/3 spiral tibia fractures (25-60%), closed, low energy fractures with acceptable alignment, < 10 degrees anterior/posterior angulation, certain patients who may be non-ambulatory (ie. 75 Tibia fractures distal to the nutrient artery may deprive the distal fragment of its medullary blood supply, and, in such cases, the distal end of the tibia must rely on its periosteal and metaphyseal blood supply for healing. compared to IM nailing of tibia fractures: increased risk of wound complications and hardware irritation, similar rates of union in closed fractures, greater radiation exposure intraoperatively, risk of damage to the superficial peroneal nerve during percutaneous screw insertion, holes 11,12, and 13 (proximally) of a 13 hole plate place nerve at risk, prior studies have demonstrated some use in, outcomes (controversial, as recent studies have not fully supported these findings), decrease need for subsequent autologous bone-grafting, decrease need for secondary invasive procedures, no current scoring system to determine if an amputation should be performed, relative indications for amputation include, most important predictor of eventual amputation is the severity of ipsilateral extremity, most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center, study shows no significant difference in functional outcomes between amputation and salvage, loss of plantar sensation is not an absolute indication for amputation, functional (patellar tendon bearing) brace at around 4 weeks, close follow-up with repeat radiographs to ensure no displacement, can wedge cast to correct slight deformity, within 24 hours of initial injury to decrease risk of infection, sharp debridement of nonviable soft tissue & bone, thorough irrigation of contaminated wound, immediate closure of open wounds is acceptable if minimal contamination is present and is performed without excessive skin tension. Patella fracture. Call regional anesthesia team to provide a nerve block, Initiate a patient controlled analgesia pump. Patella instability . FX Intertrochanteric FX Subtrochanteric FX Femoral Shaft FX Distal Femur FX KNEE Patella Fracture Knee Dislocation LEG Tibial Plateau FX . Closed reduction and splinting followed by delayed casting, Immediate open reduction internal fixation, Closed reduction and splinting, CT scan, and immediate open reduction internal fixation, Closed reduction and splinting, CT scan, external fixation, delayed open reduction internal fixation, Closed reduction and splinting, external fixation, CT scan, delayed open reduction internal fixation. (OBQ15.40) On physical exam the leg has no erythema, but does have mild tenderness along the distal tibial shaft. What is the most appropriate next step in treatment? Valgus instability of the knee is noted. A 21-year-old male sustains the injury shown in Figures A through D. Which of the following is the most appropriate definitive treatment of this injury? Two weeks following external fixation, examination reveals intact sensation, palpable pulses and no soft tissue compromise. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. Treatment is often surgical reduction and fixation in the acute setting versus delayed fixation after soft tissue swelling subsides. Following fixation, a "shuck" test is performed and shows persistent instability of the distal radioulnar joint. What is the most appropriate next step in management? This laceration is able to be closed during initial surgery. (OBQ04.69) When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT? (OBQ08.182) 2,754 followers. 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